The accuracy of the diagnosis code is a statement that shows a code for a convincing diagnosis, and has been said to be certain and clear according to the ICD-10 guidelines. The purpose of this study was to obtain an overview of the analysis of the accuracy of injury codes and external causes of injury in emergency care electronic medical records at the Jakarta Islamic Hospital Sukapura. This research is descriptive research with a Mix Methode approach. Data collection techniques using observation and interview methods. Samples were taken using saturated sampling techniques totaling 81 electronic medical records of emergency care patients. The accuracy of the injury code is 22% correct, and the accuracy of the external cause of injury code incorporated in traffic accident cases and other accident cases is 0% correct. The low accuracy of injury codes was due to not adding character 5, block code errors, and errors in determining code categories. The results of the accuracy of the external cause of injury code obtained were 0% correct because 80 electronic medical records of emergency care patients did not contain the code for the external cause of injury. Factors that hinder the accuracy of injury codes and external causes of injury are influenced by man factors, namely high workload, dependence on ICD-10 codes on doctors, and lack of feedback audits. Then the influence of material factors, namely the incompleteness of supporting documents, lack of detail in diagnosis, and lack of chronological letters of events. Then the influence of method factors, namely unsupportive policies and procedures, lack of training and understanding, and weak application of external cause of injury codes.
 

Prompt return of patient medical records is an important step in the health records processing workflow. Speed is the key to meeting quality processing standards. The hospital sets a deadline for returning medical records within 2x24 hours after the patient is discharged. Delays can be caused by various factors, which are classified under the 5M management elements: man, materials, machines, methods, and money. The aim of this research is to identify aspects that are the root of the problem in delays in the process of returning medical records to the hospital. The methodology used is a literature review, with analysis of 17 journal articles from the Google Scholar database. The study results showed that human factors such as staff shortages, incomplete doctor signatures, and inadequate staff educational qualifications were the main causes of delays. Material factors often result in incomplete documents. The machine factor is related to the significant distance between the inpatient department and the medical records department. Meanwhile, the method factor, namely SPO socialization has not been carried out and the implementation of job descriptions has not been maximized.

Shrinkage is the reduction of medical records on storage shelves by moving inactive medical records to a different room from the active shelf seen from the last patient visit. The purpose of this study was to determine the implementation of shrinkage at the Kembangan Regional General Hospital. This research method uses a qualitative descriptive method by means of interviews and observations in the medical records unit. So it can be concluded from the results of the study that the Kembangan Regional General Hospital already has SOP related to shrinkage which is divided into SOP sorting, media transfer and destruction. In the implementation of shrinkage, officers carry out the process of sorting, transferring and transferring media every day. But officers do not conduct an assessment based on use value. The destruction process is carried out when the number of medical records has reached 2 tons by using a third party to make medical records in the form of pulp. The main obstacles to the implementation of shrinkage are officers who do not have a decree on duties and teams so that officers often delay the implementation of shrinkage, paper quality that makes it difficult for officers to see medical record sheets in the past year and scan machines that heat up quickly due to continuous use. Therefore, the Kembangan Regional General Hospital should complete the SOP related to shrinkage, make a decree of duties and conduct an assessment stage so that the implementation of shrinkage is carried out properly, and add a scan machine so that the implementation of media transfer is not delayed.